PAD drives worse limb outcomes, mortality in acute MI with cardiogenic shock
Click Here to Manage Email Alerts
Comorbid peripheral artery disease is a significant risk factor for adverse events for patients with acute MI with cardiogenic shock, including worse limb outcomes and poorer short- and long-term survival compared with those without PAD.
In an analysis of more than 70,000 Medicare beneficiaries, researchers also found that patients with acute MI, cardiogenic shock and comorbid PAD were less likely to receive mechanical circulatory support; those who did had increased mortality, lower extremity revascularization and amputation rates.
“Presentation with acute MI and cardiogenic shock is associated with extraordinarily high rates of mortality,” Eric A. Secemsky, MD, MSc, RPVI, FACC, FSCAI, FSVM, director of vascular intervention at Beth Israel Deaconess Medical Center, director of vascular research at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and assistant professor of medicine at Harvard Medical School, told Healio. “During the past decade, there has been increasing attention to better recognizing the presence of shock at the time of acute MI admission and developing algorithmic approaches to caring for these patients. However, not all shock patients are equal. In particular, we recognized that patients with a history of symptomatic lower extremity peripheral artery disease may have more guarded outcomes due to both limb complications related to PAD and the greater presence of systemic atherosclerosis among patients with symptomatic PAD.”
Outcomes based on PAD status
Secemsky and colleagues analyzed data from 71,690 Medicare beneficiaries hospitalized with cardiogenic shock and acute MI, with and without PAD, from October 2015 to June 2018. The mean age of patients was 78 years, 59% were men and 84% were white. Primary outcomes included in- and out-of-hospital mortality; secondary outcomes included bleeding, amputation, stroke and lower extremity revascularization. Subgroup analyses included patients treated with mechanical circulatory support and those who underwent coronary revascularization.
The findings were published in the Journal of the American College of Cardiology.
Within the cohort, 5.9% had PAD. Cumulative in-hospital mortality was 47.2%, and was more common in those with PAD (56.3%) than in those without it (46.6%), for an adjusted OR of 1.5 (95% CI, 1.4-1.59).
Patients with PAD were also seven times more likely to experience in-hospital amputation (adjusted OR = 7; 95% CI, 5.26-9.37) and 78% more likely to experience out-of-hospital mortality (aHR = 1.78; 95% CI, 1.67-1.9) compared with patients without PAD. Mechanical circulatory support was less frequently utilized for patients with PAD (21.5% vs. 38.6%; P < .001) and was associated with higher mortality, need for lower extremity revascularization and amputation risk. Findings were similar among patients who underwent coronary revascularization.
“Patients in cardiogenic shock at the time of admission are treated differently if they have symptomatic lower extremity PAD compared to those without this condition,” Nino Mihatov, MD, a structural intervention/valve fellow at Columbia University Irving Medical Center, told Healio. “For instance, they less often receive mechanical circulatory support and less often undergo coronary revascularization. Second, patients with PAD have worse short- and long-term outcomes. This includes greater limb events during the index acute MI admission, greater in-hospital mortality and worse cumulative long-term outcomes. Even when mechanical circulatory support is utilized, these worse outcomes persist.”
Secemsky said the data show a more thoughtful approach is needed when approaching shock treatment and coronary revascularization for these patients.
“If mechanical circulatory support is indicated, one should consider alternative access site options such as axillary access,” Secemsky told Healio. “Treatment teams should also involve providers with specific vascular training to help monitor limb status. Lastly, close follow-up for those who survive to discharge is particularly warranted for those with PAD, and maximizing all medical therapeutic options is required.”
‘Identify PAD and prevent disease progression’
In a related editorial, Mehdi H. Shishehbor, DO, PhD, MPH, and Yulanka Castro-Dominguez, MD, both of Harrington Heart and Vascular Institute, University Hospitals, and Case Western Reserve University, Cleveland, wrote that PAD remains undertreated; PAD screening may help identify a subgroup of patients at especially high risk for adverse CV outcomes who might benefit from more intensive secondary prevention and surveillance.
“Importantly, we need to identify PAD and prevent disease progression,” Shishehbor and Castro-Dominguez wrote. “PAD overall remains underdiagnosed, even in patients at high risk of cardiovascular events.”
Understanding how comorbid PAD can alter a patient’s risk profile is crucial to be able to deliver the most appropriate therapies and specialized management, Shishehbor and Castro-Dominguez wrote.
“Indications for complex and large-bore interventions will continue to increase, while advances in techniques and devices will similarly evolve,” Shishehbor and Castro-Dominguez wrote. “Only with an interdisciplinary approach using expertise across different disciplines will we be able to reduce morbidity and mortality in this high-risk population with PAD.”
Reference:
For more information:
Nino Mihatov, MD, ca be reached at nm3212@cumc.columbia.edu. Eric A. Secemsky, MD, MSc, RPVI, FACC, FSCAI, FSVM, can be reached at esecemsk@bidmc.harvard.edu.
Collapse
Click Here to Manage Email Alerts